BalintANZ Auckland-Waiheke 7-10 Nov 2024 Workshop Application Form

Thank you for your interest in participating in the Auckland - Waiheke BalintANZ four day workshop. Welcome!

Information you provide is confidential to BalintANZ and the organising team for this workshop.

Contact details

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Country CodeArea CodePhone Number

Email

example@example.com

Are you a current financial member of the Balint Society of Australia and New Zealand?

YesNo

If you are not currently a financial member of the Balint Society of Australia and New Zealand, we strongly encourage you to join. You can apply for membership by clicking here.

Are you currently on the Leadership Accreditation pathway with BalintANZ?

YesNo

Do you have any food allergies or special dietary requirements i.e. vegetarian, gluten free?

If appropriate, would you be interested in being connected to others who may be interested in sharing accommodation costs? (Please be aware that accommodation at the Waiheke Island Resort is discounted by 10% for registrants.)

YesNo

BalintANZ Board is a not-for-profit society. We keep fees as low as possible and recognise that the cost of the workshop is difficult for some members. We are keen to expand our current activities and make them accessible to a wide range of professionals. To do this we need to be in a stronger financial position. This year BalintANZ is trialing a tiered registration fee system. Please nominate the highest fee level you can manage, and you will be invoiced accordingly. Please note the registration fees below are the members' rate. If you are not a member of the Society, an additional $240NZD will be added to your registration invoice. Australian residents will be invoiced in Australian Dollar equivalent.

Students, practitioners with low income - Registration fee $1,440 NZDPractitioners with medium income - Registration fee $1,550 NZDPractitioners with high income or receiving professional development support - Registration fee $1,800 NZD

If you would like to bring a companion along to the Gala Dinner on Saturday 9th November, please select Yes below.

Yes, I would like to bring a companion to the Gala Dinner

Professional information

What is your profession? (E.g. GP, psychiatrist, psychotherapist, psychologist, counsellor, veterinarian, etc.)

What are your professional qualifications?

What is your current position?

What is your professional registration body? (E.g. AHPRA, MCNZ, AASW, PBANZ etc.) If you do not have a professional registration body, please describe your circumstances.

What is your registration number with that professional registration body?

Are there any current restrictions on your registration with the professional registration body listed above?

YesNo

If yes, please describe the current restrictions on your registration.

Are you a health professional undergraduate student? Note that this includes graduate programmes such as graduate medical programmes.

YesNo

What is the name of the institution where you study?

What is your expected year of graduation?

Balint experience

Have you attended a Balint Intensive workshop previously?

YesNo

Please describe your interest in Balint group work, especially any experience in a Balint group.

Is there a current member of the Balint Society of Australia and New Zealand (preferably an Accredited Leader) who would be prepared to provide a reference for you?

YesNo

Do you consent for the Balint Society of Australia and New Zealand to contact your nominee to seek a nomination if necessary?

YesNo

Please provide the nominee's name and email address

If no nominee is available, we might contact you after you submit your application to arrange an introductory meeting with a member of the society.

Are you a member of any other Balint society? (E.g. American Balint Society, UK Balint Society, etc.)

YesNo

Please name the society.

Are you accredited as a Balint leader with any Balint society affiliated with the International Balint Federation (IBF)?

YesNo

Please name the society.

Undertakings

If your application to attend this intensive is successful, do you:

confirm that you have appropriate professional indemnity insurance (if relevant)?
confirm that you are in good standing with your professional registration body
undertake to abide by the code of ethics of your profession?
agree not to conduct yourself in any way which would bring the BSANZ into disrepute?
agree not to state or suggest that you are accredited by the BSANZ to lead Balint groups until you enrol in the Leadership Accreditation Pathway or become an Accredited Leader?

If I attend this intensive, I agree to abide by the undertakings above.

YesNo

At this stage, we advise against making travel and accommodation arrangements. We will contact you once your application has been accepted with details of how to pay your registration fee and we would suggest making your arrangements promptly then.

If you have any enquiries, please contact admin@balintanz.org

BalintANZ Waiheke Island, Auckland 7-10 Nov 2024 Four Day Workshop Application Form